Eyeworld

EW FEATURE 42 Microinvasive glaucoma surgery (MIGS) • May 2016 by Ellen Stodola EyeWorld Senior Staff Writer Recommended patients and their reactions In Canada, Dr. Harasymowycz said that the iStent has been available for about 5 years. "It's completely changed the way we approach the surgical management of our glaucoma patients," he said. The most frequent indications for use are in patients using 1 or more drops to control glaucoma and presenting at the same time with a cataract. If it is controlled glaucoma, that's the primary indication, he said. Patients with exfoliation syndrome are also generally good candidates, he added. There are many considerations when choosing in which patients to implant an iStent. "I think that you should set the iStent up for success," Dr. Bacharach said. He said it works wonderfully well along the lines of what it's indicated for: patients with elevated pressure on 1 or more med- icines having cataract surgery done. As he's gotten more comfortable using the device, he has expanded its utilization to include people with even slightly more advanced disease, particularly if they're elderly and he wants to try to avoid trabe- culectomy. Dr. Bacharach also uses the iStent in open angle glaucoma and there's a possibility that they may need more invasive glaucoma surgery, but this also increases the potential that they won't need any more surgery." Dr. Bacharach said he has placed almost 200 iStents since its com- mercialization, and he was also part of the trial before the iStent was approved. It demonstrated in U.S. clinical trials no reduction in post- operative visual acuity compared to cataract surgery alone. It is also very efficient to utilize in the operating room once the surgeon gets over the short learning curve, he said. "It's been a good part of my portfolio for my glaucoma patients who need cataract surgery," Dr. Nguyen said. He added that it's the "first of its kind" to change the way physicians approach glaucoma. It's less invasive and has an excellent safety profile and also helps to get patients' glaucoma better controlled. Dr. Nguyen said that although there was a learning curve, it was not too hard to adjust to using the device. "It's not as easy as it looks, but there are not too many surprises," he said. utilizing it in their procedures." This includes interest not only from glaucoma specialists but also from comprehensive ophthalmologists. From Dr. Bacharach's standpoint, the iStent has revolutionized how he looks at managing patients with glaucoma and cataracts. In the past, his decision was to do a trabeculectomy, and then when the cataract worsened, manage that at a second sitting. However, the problem is that when removing the cataract, surgeons can cause the original glaucoma surgery to work less effectively, Dr. Bacharach said. The other choice was to just remove the cataract, and then the question was how to manage the postop eye pressure. "Some people responded well but many didn't, and then the surgeon had to do a glaucoma sur- gery down the line," he said. This new procedure provides some assurance that the surgeon will have somewhat better control of the eye pressure, Dr. Bacharach said. "The way I describe it to patients is that it could be a 2-stage procedure," he said. "I tell them we'll do the cataract surgery and place the iStent, After several years of experience with the iStent, physicians comment on their observations using it and recommendations for successful surgery T he iStent (Glaukos, Laguna Hills, California) was the first MIGS device to be FDA approved. Now, with several years of use and data, it's showing good results and success with cataract surgery. Jason Bacharach, MD, North Bay Eye Associates, Petaluma, California; Quang Nguyen, MD, Scripps Clinic Torrey Pines, La Jolla, California; and Paul Harasymowycz, MD, Uni- versity of Montreal and Montreal Glaucoma Institute, commented on their experience with iStent since its approval and special considerations when implanting the device. Experience with the iStent "It's an exciting time," Dr. Bacharach said. "The device has become more mainstream in terms of doctors feeling comfortable • The main indications for using an iStent include glaucoma patients presenting for cataract surgery who are currently using 1 or more drops. • Placing the iStent before cataract surgery is often a good option so the cornea is still in pristine condition. • Adjusting a patient's medication after surgery is an important consideration. Some patients may have a steroid response, causing high IOP. AT A GLANCE Experience with iStent Targeted placement of the iStent can help facilitate optimal results in these procedures. Dr. Harasymowycz illustrates the blanching of the episcleral vessels when performing irrigation and aspiration, which is a positive sign for good stent placement. Source: Paul Harasymowycz, MD Scan to watch a video of Dr. Harasymowycz performing an iStent implantation. He shares how to determine if the iStent is optimally placed.

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